Monday, September 17, 2007

Health care reform isn’t only about covering the uninsured. It’s about reorganizing one-seventh of the U.S. economy. It’s the issue that will redefine the role of government in the 21st century. So when I spoke with Hillary Clinton yesterday, I asked what her newly unveiled plan revealed about her political philosophy.

The word she kept coming back to was “partnerships.” She described an array of different social entities — individuals, the federal government, insurance companies, doctors and hospitals — coming together and exercising shared responsibility for creating a better system.

It began to sound like a health care loya jirga — indicative of the political vision that has marked so much of her thinking over the years. When some politicians are asked to describe systems that really work, they think of the competitive marketplace. Others think of political combat — good defeating evil. But Clinton, at her most hopeful moments, is a communitarian. When she’s asked to describe a system that works, she describes diverse people coming together around a big table to reach a consensus.

That’s the sort of national community her plan is supposed to foster and that’s the sort of process she used to create it. Clinton is hard to interview because her answers are often just chunks of her stump speeches, but I thought I detected real warmth when she described the way she and her staff came up with the plan.

“It was an exhilarating process!” she enthused, describing how all sorts of different people came together to talk through issues. “There were countless meetings,” she remembered fondly, “with business leaders who were surprised to find themselves sitting next to me” and a long parade of academics, nurses, experts and friends.

As she spoke, memories of the Clinton years wafted through my head — government by seminar running into the late hours. But as she will tell you (before you even have a chance to ask), she has learned a lot since the early 1990s, and while the conversations may still be endless, they are also more restrained.

And it’s true. The plan she unveiled yesterday is much simpler than the one she came up with 14 years ago. Back then, she and her staff were like technocratic engineers, one of her advisers told me, trying to patch every last gap in their edifice. This time they were content to leave the details of the plan to Congress.

Last time, they threatened people who were satisfied with their health coverage. This time they reassure them that nothing will change. Last time, they were out of touch with the American values of choice and individual freedom. This time they emphasize those values every chance they get, never seriously considering a Canadian-style single-payer system.

This time the change is evolutionary, not revolutionary. The private insurance/employer-based system will still remain the heart and soul of the social contract — it’s just that more people will be given tax credits so they can afford to buy in.

The Clinton plan makes life politically difficult for Mitt Romney. She relies on an individual insurance mandate. So does his plan in Massachusetts. The Clinton plan also takes the brave step of taxing the wealthy for gold-plated health care benefits — a reform that almost every Republican health expert endorses. Meanwhile, the plan seems to have driven John Edwards around the bend. The statement he issued yesterday qualifies as the shrillest statement issued by a major presidential candidate this year.

But the Clinton plan does have the weaknesses of the communitarian approach. She creates a magic circle of companies, providers, government entities, all interlocked in a system to provide health security. But there will still be forces outside the magic circle that will be adapting and innovating in ways that might upset the plan.

First, there will be state governments. One of the virtues of welfare reform is that while the national government set certain goals, it was up to the states to innovate and compete to reach them. Clinton says she’s not averse to creative solutions from the states, but she doubts that they’ll be able to lead the way since they rely on money from Washington. Hers is not a decentralized, federal approach.

Then, there are the insurance companies, the designated bêtes noires of her plan. They are commanded to insure everybody, but they’ll probably be extremely creative in finding ways to not insure high-risk people who will cost them money.

Then there are patients. The Clinton plan aims to lower health care costs through a variety of measures. But if the cost of an M.R.I. comes down, people will just want more of them. Americans spend more on computers as those machines get more efficient.

Finally, there is posterity. Our children face a gigantic tidal wave of debt as a result of our current health care system. If health care reform doesn’t fundamentally adjust benefits while using available tax increases to help the uninsured, then the system will still be unaffordable in the long run.

Hillary Clinton’s health care plan is a huge step forward from 1993. It’s better than the G.O.P. candidates’ plans (which don’t exist). But there are still complexities in the health care system that no loya jirga, no matter how smart, can fully anticipate and control.